Paul Farmer on Working With, Not For, Developing Nations

Dr. Paul Farmer, co-founder of Partners In Health (PIH) and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, had a discussion with a packed auditorium at the Harvard School of Public Health this past Tuesday on the importance of working with, and not simply for, poor communities to increase global health equity. Dr. Farmer spoke of his focus on a country’s assets rather than its deficiencies, a strategy that has transformed the field of global health and proven effective in increasing access to high-quality health care. Through anecdotes of his work, Dr. Farmer explained how working with local communities and public-sector institutions to empower citizens can lead to successful endeavors.

Farmer began the presentation with a question: why do we expect health workers from poor areas to work for free, when they are one of the community’s greatest assets? He believes that interventions should empower local people by funding salaries for community health workers. Employing local staff is something that Partners In Health has put into action, not only because it stimulates the economy, but because local staff have local knowledge and access to patients that others may not have. A PIH community-based antiretroviral therapy program in Rwanda was able to follow up with 95 percent of its patients. This number, said Farmer, is astonishing as many initiatives have high loss to follow up rates. And low follow up rates are a problem; they mean that programs cannot track how effective their activities are.

As stated above, employing local staff means putting more funds into local economies. Farmer argued for directly funding local people and institutions rather than international consultants and evaluators. A colleague of his estimated that 50 percent of funding for public health consulting work in Rwanda goes straight to paying administrative overhead for international contractors. Of the remaining 50 percent that funds projects, generally half is used exploring initiatives that will prove ineffective. Farmer stated that if 10 percent of that funding went directly to an existing hospital, for example, they could likely cover their operational costs for 10 years. Time and resources could focus on other activities. Farmer asserted that health assessment surveys should only be funded if there is a real intention to act upon the findings. He noted that the Rwandan government even recently outlawed studies without plans of action post-assessment.

When asked whether or not one should pursue collaborating with governments, Farmer’s answer was clear, “Governments confer the healthcare rights of the people, thus effective interventions must collaborate with government in some way.” While he admitted collaborations can be challenging, PIH’s partnerships with governments have yielded effective and sustainable change. The recently built Mirebalais National Teaching Hospital in Haiti was funded almost entirely by PIH, but now the Haitian Ministry of Health has full ownership of the hospital. A partnership is in place to train doctors, nurses, and other healthcare professionals. Such an initiative supports local capacity building. Another facility, Butaro Hospital, was built in collaboration with the Rwandan Ministry of Health, which now provides 48 percent of its funding. “This is what we want to see,” said Farmer, highlighting the importance of enriching the host country institution.

Dr. Farmer has a history of working deeply within communities, making cultural awareness a priority in his health initiatives. This most likely stems from his unique training as a physician and anthropologist. The strategy has had no lack of success as is evident through PIH’s work with some of the poorest people in the world, such as those devastated by the 1994 genocide in Rwanda or survivors of the 2010 earthquake in Haiti. Enriching existing health systems, effective collaborations, and empowering communities are lessons to take from Farmer’s success, and will lead to more effective and sustainable solutions if they become standard in international public health initiatives.


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